The name of the devil

To the Editor:Dr. Lansdale’s commentary1 reveals the price we pay when we focus on one important goal to the exclusion of others. He illustrates that reductions in health care cost were paid for with reduced health care quality, and a loss of camaraderie and job satisfaction. Missing from his commentary, however, is any acknowledgment that reducing the cost of health care is an important and worthy goal—and his wistfulness for the old days suggests his willingness to trade increased cost for better quality and job satisfaction.

Unfortunately, the biggest problem in this conflict is not that Dr. Lansdale and his former administrators disagree on whether cost is more important than quality and job satisfaction, but that both mistakenly agree that each must be traded off for the others. This hidden agreement is the chief mischief in health care today.

For example, much of the effort to improve health care quality has been oblivious to costs and employee satisfaction. Efforts to reduce errors have led to additional process steps, new checkers and coordinators, and expensive IT systems. These have increased costs, while frequently reducing job satisfaction and in some cases even failing to improve quality. Computerized order entry systems have been shown, for example, to disrupt physician-nurse communication patterns that were one of the major ways the old system prevented errors, and were a source of job satisfaction to both parties.2 In some cases, patient mortality rates increased after they were implemented.3 Another new system plans to police handwashing by putting video cameras in patient rooms.4 Costly, yes, and the consequences for clinical-staff jobsatisfaction are predictable.

The core problem is focusing on one-dimensional outcomes, instead of insisting that cost, quality, and job satisfaction are all vital, and that we will not truly achieve any of them until we achieve all three. Poor quality is wasteful, and waste costs money. Employees are most satisfied where they are productively employed providing high-quality services, and productive employees cost less in the long run than unproductive ones.

How can we have high-quality, low-cost, high-satisfaction health care? By fundamentally redesigning the way care is delivered, radically simplifying care processes to focus on the limited number of elements that produce health outcomes for the patient. Toyota has demonstrated that it is possible for a manufacturer to be high-quality, low-cost, and high-satisfaction by using an analogous approach, and the many manufacturers that have followed its example testify that Toyota was no fluke.5 Early efforts are underway to apply so-called lean approaches in health care settings, but most are pruning the branches of waste instead of pulling it out by the roots, for example, redesigning labs and supply closets far from the patient’s side.6,7

A former boss was fond of quoting economist Kenneth Boulding: “The name of the devil is suboptimization!” Let’s begin by agreeing that cost, quality, and job satisfaction are all important, and commit to working to achieve all three together.